The History of American Nursing Education
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“You can track nursing’s development in tandem with war and conflict. Many training programs were developed as a response to war to meet the demand. Because of that, different pathways to nursing were always available, from apprentice hospital-based programs to baccalaureate education and associate programs that developed to split the difference.”
Patrick McMurray, MSN, RN, Nursing Educator, University of North Carolina at Chapel Hill School of Nursing
Nursing students today are taught to revere Florence Nightingale, who is heralded as the mother of nursing and the originator of modern nursing education. Nightingale was an upper-class British woman from a wealthy family who left a life of leisure to serve those in need, which was quite scandalous at the time.
Known by the soldiers she cared for as “The woman with the lamp,” she is often credited with founding the field of nursing, but in truth, nursing has been around as long as humans have, as have the institutions that train them. Starting in the home, caregiving through illness, injury, pregnancy, birth, and death has been practiced and passed down from mother to daughter and father to son for millennia.
In her book Taking Care, journalist and nursing historian Sarah DiGregorio dispels the myth that Nightingale founded the nursing profession or even invented modern nursing education. According to her, the first formalized nursing school dates back to ancient India when Buddhist Emperor Ashoka built one in 250 BCE, featuring a curriculum rooted in Ayurvedic principles (DiGregorio, 2003, p. 7).
Later, the Byzantine Empire also had a sophisticated hospital called the Pantokrator, which had multiple wards dedicated to different illnesses and genders, an outpatient clinic, a pharmacy, and even a bakery and mill to supply food for the patients run by a skilled and educated staff (DiGregorio, 2003, p. 13).
There have also been dozens of hospitals in the ancient Middle East called bismaristans, which provided advanced care and were staffed by educated professionals, what we would call nurses today. These hospitals were located in modern-day Iraq, Iran, Syria, Egypt, Saudi Arabia, and Tunisia, and they even had a standardized discharge protocol for each patient, including a bath, a set of clothes, and money (DiGregorio, 2003, p. 10).
Caregiving has always been essential to society and the war machine that grew empires from seed. None of these societies would have grown to such heights without nursing care. In ancient times, nurses were often men, though sometimes women, and often doubled as priests and priestesses. Most religions in the ancient world believed that illness was a punishment from the gods, so these caregivers provided as much spiritual care as physical care.
Later, in Western Europe, during the Middle Ages and Renaissance, nursing and healthcare developed in Christian religious orders and were often practiced by nuns and monks. Throughout this period, most hospitals and care centers were run by these orders, and thus, being chaste, virtuous, obedient, and hard-working became embedded cultural expectations for nurses that are still felt today.
“Ultimately, the nursing work of religious women was often recorded as acts of godliness and purity but not of knowledge and training” (DiGregorio, 2003, p. 18).
This devotion to caring for others as a god-given duty led Nightingale to ship off to Germany at 24 years old to study nursing at Theodore Fliedner’s Hospital and School for Lutheran Deaconesses. After additional training in France, she returned to England, where she worked as a nurse until the Crimean War broke out in 1853.
Though Nightingale did not invent nursing education, she was instrumental in establishing its legitimacy in the West for the next two hundred years. Because, like so many other medical innovations, the coming war would demand change and transformation.
Wartime Innovations in Nursing & Medicine
Medical standards of care that are taken for granted today, including cauterization, tourniquets, antibiotics, and plastic surgery, have all come from the incubator of medical innovation that is war. Incredible discoveries gleaned from battlefield medicine have always trickled down into civilian healthcare and education and become standard practice.
When the Crimean War broke out in 1853, the state of wartime healthcare was abysmal, and the lack of sanitation, supplies, and trained medical staff had catastrophic results. The situation was so dire that more soldiers were dying of infection than on the battlefield.
At the time, Florence Nightingale was the manager of a women’s hospital in London, and according to the National Women’s History Museum, it was then that the Secretary of War, Sidney Herbert, wrote to Nightengale and asked her to take a group of nurses to help treat wounded soldiers at a struggling British army camp outside of the city of Constantinople. She agreed, and in 1854, she and her small group of nurses shipped off to war.
Introducing Sanitation and Order
When the nurses arrived, they experienced hostility and suspicion. The male soldiers and their commanders were incensed at the very idea of working alongside women and did not value their knowledge or expertise. Yet Nightingale and her team endured.
Despite their initial misgivings, the British military leaders were forced to concede when the camp overflowed with wounded. So Nightingale set to work with a keen focus on sanitation, nutrition, and order.
All areas were cleaned and ventilated, surgical theaters were separated from recovery areas, and this small group of trained nurses turned the field hospital around in short order. Incredibly, these changes dropped the soldiers’ death rate from 40 percent to a mere 2 percent.
After the war, Nightingale returned to England and advocated tirelessly for structured nursing education. She eventually published a book titled Notes on Nursing: What it is, and What it is Not, in which she shared her insights on nursing care that would serve as the foundation for the first wave of nursing schools in America. Eventually, Nightingale put her educational opinions into action and founded her own nursing school at St. Thomas Hospital in London in 1860.
According to The Historical Development of Nursing Education, though Nightingale did not invent the field of nursing, her revolutionary ideas shaped modern nursing education in the West, for good and for bad.
On the one hand, Nightingale firmly believed that nursing schools should be independent from the hospitals where they worked. This idea was novel, as historically, hospitals had exploited nursing students for free labor and provided minimal academic instruction. She also believed that nurses should have dorms provided for them, their instructors should be paid, and that schools should correlate nursing theory with practice. Indeed, these ideas were revolutionary at the time.
Yet Nightingale has a mixed record because she did not grasp germ theory and thought cleanliness was enough to prevent illness. Most importantly, she had powerful feelings about who could be a nurse, chiefly pious, chaste, unmarried upper-class white women. She sought to achieve credibility for the profession by embracing the rigid class and gender expectations of the British upper class, which held the profession back for decades.
“She did advocate for nursing as a trained profession and for public health sanitation measures, but as she did so, she shrank nursing into a restrictive Victorian corset, constructing a version of nursing that conformed to rigid social mores, one divided by class, race and gender” (DiGregorio, 2003, p. 5).
Nightingale’s views would become foundational standards of the profession.”…her emphasis on hierarchy and propriety has permeated nursing—as seen in the often extreme rigidity of nursing education, even today, with some nursing students doing their clinical training penalized for wearing the wrong socks or having a visible tattoo or natural Black hair.” (DiGregorio, 2023).
Despite these shortcomings, the Nightengale model was embraced by the white ruling class of Western Europe, and soon, the United States would follow suit.
The Civil War Revealed a Need for Educated Nurses
Across the ocean, the Civil War was ravaging the American landscape, and the same infection rates were experienced by both the Union and Confederate forces. Scores of family and community members flocked to the war camps to provide aid, but this did little to stem the deaths from infection, thanks in large part to a lack of formal training these volunteers had. “The sorely felt need for trained nurses did spur the development of the first real nursing schools in the United States” (Anderson, 1989, p. 16).
Early American Nursing Education
Before Nightingale published her treatise on nursing education, any nursing educational programs that existed in the US were scattered and not remotely standardized. Like the hospital-based programs that Nightingale had criticized in Europe, many were run by hospitals solely to provide free labor and were very light on actual education. But in 1873, the first three formal nursing schools in America would open, each following the Nightingale method.
After that, nursing programs started popping up nationwide, and the first black nursing school opened in 1891. While most of these programs drew inspiration from Nightingale’s published works, there were no accrediting bodies, and each school had different teachings, lengths, requirements, and rules.
When the Spanish-American War began in 1898, only nurses who graduated from a formal training program were allowed to serve in the war. By 1900, there were more than 2,000 nursing programs nationwide, most of which were two to three years long.
Modern Nursing Education’s Origin
Yet again, the war would push the American nursing education system to innovate. Admissions to nursing school jumped 25 percent once the US entered World War I, which led the government to found the Army School of Nursing and create the Vassar Training Camp to meet the growing needs of the military.
The Vassar Training Camp was a three-month intensive program designed to provide nurses serving alongside military personnel with the necessary natural and social science knowledge and fundamental nursing skills to provide care. After their service, these nurses completed the rest of their two-year training program in one of 35 affiliated schools.
American nursing schools recruited even more students during World War II, and the Cadet Nurse Corps (CNC) was founded. The CNC allowed nursing students to leave and provide patient care to the military for the last six months of their program. By the war’s end, nurses were recognized for their invaluable service, and the need for highly trained nurses continued to increase in the civilian sector. These innovative abridged programs proved that nurses could be taught necessary skills and knowledge in shortened timelines in times of need.
Despite Nightengale’s beliefs that nursing was the duty of “proper ladies,” the dire need for skilled nursing care led to the proliferation of nursing programs that predominately served poor and working-class women who wanted a respectable profession. In fact, nursing education in America was founded in part to empower and employ lower-class women. Of the first three nursing schools to open, Massachusetts General Nurses Training School was opened with the explicit intent to provide career opportunities for women.
“You can track nursing’s development in tandem with war and conflict. Many training programs were developed as a response to war to meet the demand. Because of that, different pathways to nursing were always available, from apprentice hospital-based programs to baccalaureate education and associate programs that developed to split the difference,” shares University of North Carolina at Chapel Hill School of Nursing nurse educator Patrick McMurray, MSN, RN.
Due in part to this mixing of classes in nursing, differing academic opinions began to emerge in the 1930s along class lines. Some believed nursing should be embedded in the university system. At the same time, many educators desired free-standing nursing schools independent of the student apprentice model that had long been common in Europe and the US and were more accessible than universities were to poor women. The hospital-affiliated training programs endured, however, eventually called diploma programs and were looked down on by university-educated nurses.
Educational Pathways Into Nursing: A Complex Web
Today, the American nursing educational ecosystem represents those nuances of thought and historical contexts. Unlike other healthcare careers, such as medicine, which has a very regimented, uniform series of steps physicians take to become doctors, nursing education has multiple entry points and even more advancement options.
Physician educational structure is rigid, in large part due to the elitism that has long governed their profession. Doctors historically came from wealthy families, as only men of means could afford the expensive education. Therefore, admission was highly selective, and the coursework was more regimented.
Nursing education, conversely, has developed more organically to reflect the multiple races and classes that have long participated in nursing education in America.
When discussing nursing, one must note two designations: 1. Degree type and 2. License (LPN/RN). There are four paths to becoming a nurse, each with different program lengths, prerequisites, and curriculums.
- Licensed practical/licensed vocational nurse (LPN/LVN)
- Diploma-prepared registered nurse (RN)
- Associate degree-prepared registered nurse (RN)
- Bachelor’s degree prepared registered nurse (RN)
Licensed Practical/Licensed Vocational Nurse (LPN/LVN)
Known primarily as LPNs, these nurses provide nursing care under the supervision of, or often alongside, registered nurses (RNs). They have a more limited scope of practice, and the program length is shorter, typically one to two years.
LPN programs have historically been the most accessible entry point into nursing for low-income and racially marginalized nurses and also tend to work in lower-paying, less-resourced facilities like nursing homes and rehab facilities. Many hospitals have phased out LPNs from care roles, preferring RNs.
Diploma-Prepared Registered Nurse (RN)
These programs are the offspring of the hospital-apprentice models that Nightingale chaffed at, though they are much improved. Diploma nursing programs are typically two to three years long and prepare students to become RNs, though they do not confer a degree. Critics of these programs have long alleged a lack of rigor compared to the university-based BSN nursing programs, and as such, only a handful of these programs exist today.
Bachelors Degree-Prepared Registered Nurse (RN)
As early as 1917, nursing educators started advocating for nursing education to be embedded into the university system, though the idea only caught on in the 1950s. These programs began as five-year programs but were eventually shortened to four years to match the rest of the university system. Due to a nursing shortage in the 1990s, accelerated BSN programs were devised for applicants with non-nursing degrees to enter the nursing field as quickly as possible. Today, traditional four-year BSN and accelerated programs prepare nursing graduates to be RNs.
Associate Degree-Prepared Registered Nurse (RN)
Lastly, associate degree nursing (ADN) programs were the last degree to be developed to provide the best of the rigorous clinical preparation standard in diploma programs and enough didactic classroom learning to place their graduates on par with BSN graduates.
The experiment paid off, and ADN programs became the most popular nursing programs nationwide. By the 1990s, they produced almost 60% of all newly licensed RNs (Ervin, 2017, p. 15).
Elitist Pressures in Nursing Education
Arguments about which nursing pathway is better–and who is a ‘real’ nurse—have raged since the inception of the first American nursing schools in 1873. From the beginning, some nursing educators sought to instill a professional hierarchy in which some nurses were more valued and respected than others. That battle has waged on for more than 100 years.
“There have always been forces in nursing that have attempted to gatekeep what they thought nursing should be. That has manifested as throwing mud at LPN and ADN programs in a concerted effort to paint them as less than,” McMurray said.
This conflict manifested in earnest when the American Nurses Association published a position statement in 1965 formally recommending that a BSN degree be the minimum entry level into the profession. According to the authors, nursing was a continuum “composed of vocational, technical, and professional segments…” (Ervin, 2017, p. 16).
“Since they couldn’t say LPN, diploma, and ADNs weren’t nurses, so they decided they weren’t ‘professional’ nurses,” McMurray said.
Though the paper was controversial then, the writing was on the wall, and the educational expectations were clear. So, over time, more emphasis was placed on the superiority of BSN education, and many nursing educators believed that LPN, diploma, and ADN programs should be phased out or even eliminated. This movement, dubbed entry into practice, has been vigorously championed by all nursing education and nursing organizations since, including the American Association of Colleges of Nursing and the American Nurses Association.
Despite nearly 60 years of pressure and numerous attempts, the campaign to make a BSN degree the minimum entry point to become a registered nurse has failed, while only one state (New York) has successfully implemented legislation.
“We have lots of on-ramps into nursing because we need them. Though we’ve tried to make BSN a requirement, I think we’ve shot ourselves in the foot given the nursing staffing shortage nationwide.” Elaine Foster, PhD, MSN, RN, vice president of nursing for Fortis Colleges and Institutes, said. “While there are clear benefits to BSN education, we need to be inviting more people into the profession, not less.”
Given the dire need for registered nurses in 2024, it appears that even the AACN has acknowledged that its elitist educational policies may have backfired based on a report they published this month.
“Despite facing enrollment challenges, nursing schools are committed to expanding their programs in response to the growing demand for nurses in all settings where health care is delivered,” said Dr. Deborah Trautman, AACN president and chief executive officer. “As we consider the needs of the nursing workforce over the next 10 years, more federal and local support is needed to expand pathways into nursing to ensure an adequate supply of clinicians needed to provide primary, preventative, and specialty care to an increasingly diverse patient population.”
The Future of Nursing Education
What is the state of nursing education today?
Modern nursing is a unique profession that has partly developed as an empowering way to help women better their lives by accessing employment while providing skilled, knowledgeable patient care to those who need it most. Since then, it has expanded to include students of every gender, race, and identity.
As healthcare has grown to understand the importance of a diverse medical team that looks like the people it cares for, diversity in nursing education—once considered a nuisance to be squashed—is clearly one of the profession’s greatest strengths.
“We live in a society where a career in nursing is still not available to everyone, and yet we have a huge nursing shortage. Therefore, there will always be a need for multiple entry points into the profession to make it more accessible and equitable. In the context of the United States, it makes sense that multiple educational pathways have developed,” Patrick McMurray, MSN, RN, UNC nurse educator, shared.
The many educational entry points available to enter the nursing field today in the US have deep roots in the class, race, and gender conflicts waged in the society in which they developed and the times in which they evolved.
The modern nursing education lattice was built to accommodate entry to women of lower economic means and social standing who helped shape the profession. Today, BIPOC and low-income nurses predominantly enter the profession through LPN, ADN, and diploma programs, providing invaluable care to their communities. Thus, these programs should be funded, supported, and expanded to help meet the dire needs of the nursing profession today.
Meg Lambrych, RN
WriterMeg Lambrych is a registered nurse, writer, and nursing advocate from Upstate New York.
After leaving clinical care due to burnout, she dedicated her life to covering issues in healthcare, nursing, and health in the digital space. She reports on nursing culture, policy, and history and interviews nursing innovators and leaders shaping the profession and challenging the status quo.